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r <br /> ENVIRONMENTAL HEALTH DEPARTME T <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFOTION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPE /YAND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> bor tory) <br /> TO RELEASE ANY AND ALL ANALYTICAL O TION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS A BLE AT THE SAME <br /> TIME IT IS PROVIDED TO ME O MY REP NTATIVE. <br /> .BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (P ease Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHO <br /> E 23 046 (Revised 02/20/09) <br /> 5 <br />